| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
12 |
12 |
$480.00 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
28 |
28 |
$405.00 |
| V2020 |
Frames, purchases |
42 |
42 |
$400.00 |
| 92015 |
Determination of refractive state |
42 |
42 |
$280.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
42 |
42 |
$140.00 |
| V2103 |
Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens |
12 |
12 |
$130.00 |